A hard day’s night

April 25, 2009

It is estimated that the annual sales of pills for sexual difficulty in men, known as erectile dysfunction (E.D.), amounts to about $3 billion per year. In the U.S. 25 million men are affected. By age 40-50 about 5 percent need help and this goes up to 25 percent of men in their 60's. The truth is that nearly every man occasionally has difficulty getting or keeping an effective erection. It is a myth that sexual activity is a hobby only of the young. In one survey 50 percent of men over 70 had intercourse once a week. The most commonly sold prescription medications for E.D. include Viagra, Levitra and Cialis. Until 1998, when Viagra came on the market, men who suffered from E.D. often became withdrawn and emotionally as well as physically unavailable to their partners. In 2003 the FDA approved Levitra and Cialis and this previously very embarrassing issue further began to change with more effective simple treatment becoming available. In spite of this a study in 2003 showed that 74 percent of men still were too embarrassed to discuss erectile dysfunction with their physician. Not all doctors are comfortable or knowledgeable enough in this area of medicine. Today, it is not unusual in my practice for men to eagerly seek help for E.D.

The most common cause is poor circulation which reduces the amount of blood flow into the penis, required to have an effective erection. Any medical condition that causes atherosclerosis or hardening of the arteries can be responsible. In fact, blocked coronary arteries exist in 30 percent of men who have erectile dysfunction and there may be no symptoms. Factors that reduce normal arterial blood flow include cigarette smoking, diabetes, high blood pressure, alcoholism, normal aging and depression. In addition there are many prescription drugs with side effect that can cause male sexual problems. Occasionally, a lack of testosterone or abnormal thyroid gland function can be the culprit. An appropriate physical exam as well as specific blood testing needs to be done to look for a possible treatable cause before prescribing a pill such as Viagra. Poorly controlled diabetes can cause nerve damage, which also can contribute to impotence. Men who have had prostate surgery or take blood pressure medication often are affected. As much as 20 percent of erectile dysfunction cases are due to purely psychological issues such as anxiety, depression, stress, performance anxiety or relationship difficulties. A man who smokes one pack of cigarettes per day has a 60 percent increased chance of having erectile dysfunction. Even riding a bicycle more than 3 hours a week can cause problems.

Treatment options other than the 3 drugs mentioned above include use of a vacuum pump and insertion of a tiny pellet or medication directly injected into the penis (ouch). They all serve the same purpose, which is to enable the penis to fill with blood when aroused. There are certain drugs, including nitroglycerin, as well as alpha blockers (Flomax is an exception), which can be dangerous combined with E.D. medication. Overall there is a 60 to 70 percent success rate. However this drops down to 50 percent in diabetics and 30 percent in men who have had radical surgery for prostate cancer. Men with diabetes, especially when poorly controlled, have twice the chance of developing E.D. Viagra, the drug most often prescribed, has been shown to be less effective when the diet is very high in fat. Erection suitable for intercourse can occur 30 minutes after taking the pill and the ability to have an erection can last more than 4 hours. The same is true for Levitra. Cialis, on the other hand has a much longer sustained duration of effect up to 36 hours. None of these drugs should be used if there is unstable cardiovascular disease. Also be aware that purchase over the Internet or from cheap mail-order pharmacies can result in useless or even harmful counterfeit medication. When a patient's insurance balks at paying for it I may need to write a letter indicating the medical reason why these drugs are necessary. Men should not be shy or embarrassed about discussing this problem with their doctor. I try to determine if the cause is poor circulation or possibly psychological. Sudden onset suggests that it is likely to be an emotional issue. When emotional rather than physical factors are at play a valid metaphor is that the light bulb still works just fine but only the switch is broken. Counseling can be of great help in such cases.

Viagra costs as high as $15 per tablet regardless if it is 25 mg, 50 mg or 100 mg. Very few users require the 100 mg dose, so it pays to cut the tablet in half or quarters using an accurate pill splitter. Also, by using the lowest effective dose the chance of side effects is much less. 80percent of men with E.D. are overweight. Exercise, weight loss and maintaining good physical condition can enhance sexual performance as well as enjoyment in both men and women. This is a normal part of life and we should not keep it hidden in the closet. See a doctor who is comfortable talking about SEX.